09020021 CITY OF CUPERTINO �r T �t
BUILDING DIVISION PERMIT 4� L� � ll r
BUILDING ADDRESS: PERMIT NO.
7532 NEWCASTLE DR AFFORDABLE WATER HFATRES F, nq02nn2l
OWNER'S NAME: PERMIT ISSUE DATE
-`r0 SA CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
RPLC WATER HEATR
BLDG ELECTPLUMB
0
u O p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in full force and eff b2)?r
License Class Lic.X
K-0 Date Contractor
ARCHITECTS DECLARATION
W U I understand my plans shall be used as public records
4
Loy Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
a O following mason.(Section 7031.5,Business and Professions Code:Any city or county
K m IgE which requires a permit to construct,alter,improve,dcmollsh,or repair any structure
y Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
tom-C (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy
not more than five hundred dollars($500). P Y Type
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Conuactoes License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li.
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
.ion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compenn�sa11fion Insurance carrier and Policy number are:
Cartier.�C r,7 tic Polity No.: Ef5$ O 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section recd not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workcrs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code•you must
.J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
z�
CONSTRUCTION LENDING AGENCY
E-t►�.r 1 hereby affirm that there is a construction lending agency for the performance of
ai the work for which this permit is issued(Sec.3097,Civ.C.) -
W�.0 Lender's Name
2 Lender's Address
U Q 1 certify that 1 have read this application and state that the above information is
LL" correct I agree to comply with all city and county ordinances and state laws relating to
C)6'0
building construction,and hereby authorizt representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hto liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequent f the granting of this per it.
t--� APPLI UNDERSTANDS WILL COMPLY WITH AL 7NN71NT Issued bv: Dateso nos. G
9 Re-roofs
Signaturto—fAliplicant/i6nLractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of hoof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muni' I Code,Chapter 9.12.and the Health and Safety
Code,Section 25532(a)?
❑Yes No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminantsas fined by the Bay Area Air Quality Managemcm all new r-iaterials for inspection.
strict?
❑Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Hcalth&Safety Codc, 25505,25533 and 25534.1 understand that if the building
docs not currently ha ant drat it' my responsibility to noK?4e
ant of the
reyuiremc ie t x r to issuance of a Certificate Signature:of Applicant Date
7 64
Owner or authorized agent Dae All roof coverings to be Class'�W'or better
a(rL
CITY OJN CUPERTINO J� c70WATI�R' HEATER
OF
CUPER,TINO PERMIT APPLICATION FORM
APN # Date:
3� (, 1 -7oao . �� 2- :3
Building Address:
53a- rvk�` cc,si-1 k- 1)c
Owner's Name: Phone #:
Contractor: Phone #: 6&1- 1 Sq - 71 3 1
�FFordah 1 e Wa-rer (-�ea�e rs
Fax #: b b I - ,Is-y - 9 SS 6
Cupertino Business License #: Contractor State License #:
.� 6 t5b 64-7 36 9
Contact: Phone #: to 0 5a-o
Scott Little-Ffelcl
Fax #:
Building Permit Info:
Bldg ❑ Elect Plumb Mech
Residential ] Commercial ❑
Job Description:
Strapped On Platform ❑ Bonde 3 ryf New Location ❑ Replacement
Valuation:
Green Building Check must be completed and attached to this application.
Green Building Points achieved: -�j